Illinois Hospital Association

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September 13, 2007

Present on Admission Reporting Requirements

While seemingly viewed by many as a data reporting or billing issue, IHA wants to make sure you are aware of the potential impact of the Present on Admission code for Medicare billing and Illinois hospital Consumer Guide reporting.

In the past few weeks, IHA has received many calls from hospital providers seeking clarification on reporting responsibilities and requirements as there are many misperceptions of what is required and when and by whom. This memo will help clarify hospital requirements.

Present on Admission Code Background
The Present on Admission code will be linked to every inpatient diagnostic code and will basically determine whether a condition or disease was present upon admission to the hospital or occurred during the stay. There are also three other codes that allow a provider to identify whether the information could not be determined from the medical record documentation; was exempt from reporting; or could not be clinically determined. This last code, "could not be clinically determined", was advanced to a national discussion and debate by the Illinois Hospital Association with successful adoption by the National Uniform Billing Committee and National Center for Health Statistics. In consultation with clinicians, IHA was able to successfully make the case that there are instances when clinical findings and screenings may not result in a determination whether a condition occurred prior to or during the stay.

Detailed information on the Present on Admission reporting guidelines can be found in the National Center for Health Statistics supplement to the ICD – 9 – CM Official Guidelines for Coding and Reporting. The Present on Admission Guidelines are also available by clicking here. Significance of the Present on Admission Code. The Present on Admission Code has been required for public reporting in California for over a decade and for the past few years in New York. Most recently many states throughout the nation are now requiring it for public reporting. States that are requiring the present on admission codes are using the information to identify hospital and public health issues on infections, complications, adverse events, etc.

In March 2005, the Medicare Payment Advisory Commission (MEDPAC) urged Medicare to implement and utilize the Present on Admission code for their payment system. In 2006 the National Uniform Billing Committee adopted the Present on Admission code for hospital inpatient claims. Prior to the NUBC adoption, the American National Standards Institute adopted the Present on Admission code for the HIPAA Claim 837 5010 and in 2006 modified the 837 4010 A1 to accept the Present on Admission code.

In 2007, the Centers for Medicare and Medicaid Services released two draft white papers on Value Based Purchasing with reference to the Present on Admission coding. In spring and summer 2007, Medicare released their proposed and final rules for the Inpatient Prospective Payment System that included the requirement for inpatient PPS hospitals to report the Present on Admission code. Furthermore, for the initial 8 conditions that Medicare identified as being avoidable in hospitals and would result in a reduction in payment starting October 1, 2008; the determination of whether that condition occurred prior to or during the stay will be based upon the Present on Admission code and therefore any payment changes will be based upon the Present on Admission code.

Medicare Requirements
Medicare is only requiring that hospitals submit the Present on Admission (POA) code on their inpatient claims for Inpatient PPS hospitals. The Medicare reporting requirements are as follows:

October 1, 2007 – Hospitals should begin reporting POA code for inpatient PPS discharges. Hospital claims submitted via Direct Data Entry (DDE) will not be able to report until January 1, 2008 when the DDE screens will be changed to accept POA

January 1, 2008 – All inpatient PPS discharges should have the POA code on the claims. Hospitals that fail to report the POA code will receive a remittance advice remark code informing them that they failed to report a POA code

April 1, 2008 – All inpatient PPS discharges must have a POA code on the claim or Medicare will reject the claim and the hospital will need to re-submit with the POA code on it.

Medicare recently updated its Medicare Learning Network Matters document on Present on Admission reporting requirements on September 11, 2007. This recent update provides greater clarification and specificity. This document can be viewed by clicking here.

Illinois Reporting Requirements
Under the Consumer Guide rules adopted on June 26, 2007; Illinois hospitals that report their inpatient discharge administrative data to the Illinois Department of Public Health (IDPH) must report the Present on Admission code on all inpatient discharges. All Illinois hospitals that report inpatient data to IDPH must report this code starting January 1, 2008 on their expanded reporting format or the HIPAA 837 4010 A1 claim version – there are no hospitals exempted from this reporting. Under SB 233, Public Act 095-0312, hospitals are also required to report the Present on Admission code for MRSA diagnoses (ICD-9-CM Code V09.0).

Hospitals are required under the Consumer Guide rules to complete a successful test of the new reporting requirements by December 31, 2007. For additional information on reporting requirements and timelines on the expanded Consumer Guide data reporting, click here (IHA web site) or http://www.compdatainfo.com/ (COMPdata web site).

IHA Support
IHA has held several telephone conferences free of charge since the beginning of this year on Present on Admission and will be announcing more shortly. A copy of the PowerPoint presentation is available by clicking here.

If you have additional questions, please contact Pat Merryweather at pmerryweather@ihastaff.org. Thank you.